This is a joint service delivered by Mr Joel Dunning (Cardio-thoracic surgeon) and Mr James McVie (Orthopaedic surgeon). Patients are usually operated on in orthopaedic trauma theatre.

Benefits:

• Restores chest wall integrity and respiratory mechanics
  
• Reduces respiratory failure and pneumonia
  
• Reduces duration of ventilatory support and length of ICU stay
  
• Reduces pain
  

 

Evidence:

• NICE guideline IPG361: Current evidence on insertion of metal rib reinforcements to stabilise a flail chest wall is limited in quantity but consistently shows efficacy. In addition, there are no major safety concerns in the context of patients who have had severe trauma with impaired pulmonary function.
  
• Review article: Operative stabilization of flail chest injuries: review of literature and fixation options. Eur J Trauma Emerg Surg (2010)36:427-433
  
• 2 RCTS: Taneka et al: 37 pts, 18 pts fixed vs 19 pts standard mechanical ventilation. 10.8 vs 18.3 days ventilated, 16.5 vs 26.8 ICU days, 61% vs 5% return to work at 6 months. Granetzny et al: 20 pts fixed vs 20 pts adhesive strapping, 2 vs 12 days ventliated, 9.6 vs 14.6 ICU days.
  
• Several case series and retrospective case match control studies with similar outcome improvements.
  

Indications:

Any trauma patient who is requiring mechanical ventilation or is heading towards mechanical ventilation due to respiratory failure (or pain) with:

• Flail segment involving 4 or more ribs or
• 4 or more displaced rib fractures per side.
  
• There must also be a reasonable expectation that the patient will ultimately recover from their injuries and will not fail to wean from ventilation for other reasons such as devastating head injury / hypoxic brain injury for example.
  

Investigations:

• Thorax CT scan (usually performed as part of major-trauma ‘pan-scan’).
  
• Contact the CT department to request 3D reconstruction (asap – this is not always possible several days after admission as some data is deleted). Consider asking for 3D reconstruction in any patients with complex or multiple rib # even if not currently ventilated in case they subsequently require ventilation and meet the fixation criteria.
  

Referral:  Please discuss any potential patients

• Out of hours: Inform on-call Orthopaedic team and on-call Cardiothoracic team so that the case can be discussed at the morning orthopaedic trauma meeting.
  
• In Hours: Contact Mr Dunning or Mr McVie directly via switchboard or via Nicola Lipscombe – Trauma co-ordinator
  
• The procedure is usually scheduled within 24-48 hrs on the orthopaedic trauma list
  

Pre-op preparation:

• Fast for 6 hrs pre-op as per Anaesthetic guidelines
  
• Optomise cardiovascular parameters (fluid fill, optomise Hb, correct coagulopathy)
  
• Ensure appropriate group and save sample
  

Post-op management:

• Supportive ICU care
  
• Lung protective ventilation strategy: BiPAP- ASB, High PEEP, Tidal volumes 6-8ml/kg, Pmax 30 cm, permissive hypercapnia (if required/no contraindications).
  
• Assess the potential for early extubation
  

Further information:

NICE IPG361 www.nice.org.uk/guidance/ipg361

Information for patients / relatives:

www.nice.org.uk/guidance/ipg361/resources/ipg361-insertion-of-metal-rib-reinforcements-to-stabilise-a-flail-chest-wall-understanding-nice-guidance2